BLET Checklist Fall 2019 Night Academy

Name ___________________________________________________________________

Date of Birth _____________________________________________________________

SSN ____________________________________________________________________

Sponsor _________________________________________________________________

1. BCCC Application

2. BLET Application

3. Sponsorship

4. Proof of High School Graduation – need copy of high school diploma or copy of GED or (2) or (4) year degree

Diploma GED

5. U.S. Citizen Birth Certificate- must have a copy

6. Medical Examination-(F-2 form)

7. Medical Statement-(F-1 form)

8. CS Exposure

9. Counties of Residence List all counties within NC and any other states you have lived since being an adult. 1.____________________________________2. ____________________________________ Additional _____________________________

10. CCHCertified Criminal Records checks from all counties lived in N.C. and outside of state

1.____________________________________2. ____________________________________ Additional _____________________________

11. Reading Assessment

12. OTHER __________________________________________________________________________________________________________________________________________________________________________________________________________________________

If past military service, need copy of DD214 and NCIS check from the branch of service you served in.

Need NC Driver’s License certified record

Beaufort County Community College

Basic Law Enforcement Training

5337 Hwy 264 EastWashington, NC 27889

Fall 2019

Dear Prospective BLET Student:

Thank you for your interest in attending the upcoming Basic Law Enforcement Training (BLET) Academy here at Beaufort County Community College. The BLET program is accredited by the North Carolina Criminal Justice Training and Standards Commission and the North Carolina Sheriffs' Commission. Anyone seeking to become a sworn officer with a law enforcement agency in North Carolina must take the course in its entirety and pass the state exam. The course consists of 34 different subject areas involving training for inexperienced law enforcement officers.

This course will be offered during the hours of 5:30 pm to 11:00 pm on Monday through Thursday and some weekends as dictated by scheduling needs. The class will initially meet on August 5, 2019 at 6:00 p.m. in Building 10, Room 32, for MANDATORY Pre-Orientation. Regular class will begin Monday, August 19, 2019. It is important that you attend the Pre-Orientation session so that the director can inform you of anything you may be missing for the August 19, 2018 start of class.

*An alternate Pre-Orientation date is needed due to inclement weather; the next date for Pre-Orientation will be August 6, 2019.

Deadline for all application packets to be turned in is August 5, 2019.

To register for BLET and begin a career in law enforcement, take the following steps:

Fill out the enclosed BCCC BLET application.

Complete BCCC admission form and return to Admissions Office. (Building #9)

Complete Reading Assessment test at BCCC. Make test date with Kimberly Jackson (252-940-6252) or Shelby Phillips (252-940-6443). You are only required to take the reading comprehension portion of this test. Please inform the tester that you are a prospective BLET student.

Obtain a medical examination by a medical doctor and complete enclosed medical forms, (F1and F2.

Copy of birth certificate in the US (i.e. - birth certificate).

Copy of high school diploma or GED completion.

Obtain a certified criminal history record check for all counties in which you have resided since becoming an adult. In the state of North Carolina, that would be age 16. If you have served in the military, you will need to request information from your appropriate branch of service as well as a copy of your DD-214. Also, prior military applicants will need a criminal record check for time served in the military. Please see Ms. Jo Linda Cooper, Office Manager, in Building #3, Office 108 for information on military criminal record checks.

All certified criminal record checks must be original, certified documents with a raised seal to be accepted. No online computer checks will be accepted.

If you have resided in the states of New York or Florida, a statewide criminal record check is required. Please send for criminal record checks for New York and Florida at the following addresses or use the website to request your criminal record check.

New York State Division of Criminal Justice Services4 Tower PlaceAlbany, New York 12203-3702Phone (518) 485-7675www.criminaljustice.ny.gov/ojis/recordreview.htm

Criminal Justice Information ServicesP.O. Box 1489Tallahassee, Florida 32302-1489Phone (853) 410-8109www.fdle.state.fl.us

Attend the first day of class, register, and pay all fees including a $36 student activity fee if you are not on financial aid — sponsorship letters do not take care of the $36. Turn in all necessary, completed paperwork to the Director.

Obtain a sponsorship from a law enforcement agency (the Director will explain this process), although this is not required, it will enable the student to save the cost of tuition. Form enclosed.

Obtain a certified copy of your driving history. North Carolina’s driving history can be obtained and printed by going to www.ncdot.gov/dmv/records.

I look forward to working with you to help attain your goal of certification as a law enforcement officer in the State of North Carolina. If you are interested in applying for financial aid to help you attend BLET here at Beaufort County Community College, please contact Ms. Jo Woolard, Director of Financial Aid, at 252-940-6219. If you have any questions about the program or its requirements, please feel free to contact me by calling 252-940-6228 or visiting my office in Building 10A on the BCCC campus. You may also contact Ms. Jo Linda Cooper at 252-940-6208, who will be more than happy to assist you in this process. Her office is located in Building #3, Office #108.

Sincerely,

Larry BarnesLarry Barnes, BLET School DirectorBeaufort County Community College

ADMISSION REQUIREMENTS AND GROUNDS FOR DISMISSAL

Basic Law Enforcement Training AcademyA. ADMISSION REQUIREMENTS/PROCEDURES

In addition to regular Beaufort County Community College admission requirements, the following apply to the BLET program:

1. Each candidate must meet the minimum standards for employment as established by the N.C. Criminal Justice Education and Training Standards Commission and/or the N.C. Sheriffs' Education and Training Standards Commission.

A. The portion of these rules that apply to initial certification are stated as follows and the trainee must:

(1) be a citizen of the United States;(2) be at least 20 years of age (trainee may be granted authorization for early enrollment

with prior written approval from the Director of the Standards Division as long as they turn 20 years of age prior to the date of the State Comprehensive Examination for the course

(3) be of good moral character pursuant to G.S. 17C-IO.

B. Also, in accordance with 12NCAC09B.0111 of Minimum Standards for all Law Enforcement Officers, the trainee shall:

(1) not have committed or been convicted of:a. a felony; orb. a crime for which the punishment could have been imprisonment for more than two

(2) years; orc. a crime or unlawful act defined as a "Class B misdemeanor" within five (5) years

prior to the date of the application for employment (in this context "enrollment"); ord. four or more crimes or unlawful acts as defined as "Class B misdemeanors"

regardless of the date of conviction; ore. four or more crimes or unlawful acts as defined as "Class A misdemeanors" except

the applicant may be employed (admitted) if the last conviction occurred more than two (2) years prior to the date of application for employment.

(2) be a high school graduate or have passed the General Educational Development (GED) Test indicating high school equivalency. The above rules and regulations are subject to change by the North Carolina Justice Department and therefore are subject to revision by Beaufort County Community College in accordance with those changes.

2. Each candidate must provide true and accurate information concerning his/her background. Any information provided by the student during the interview or application process that is determined to be false or inaccurate will be grounds to deny entry into or dismissal from the BLET program.

3. Each candidate must provide BLET officials with a certified copy of his /her arrest and driver’s history record for the past five years.

4. Each candidate must be twenty years of age as of the initial (first) day of class or have prior written authorization from the Director of the Criminal Justice Standards Division if less than twenty years of age.

5. Each candidate, by the initial (first) day of class, must provide the BLET Director a medical examination report form properly completed by a physician or a nurse practitioner or physician’s assistant licensed in North Carolina.

B. GROUNDS FOR DISMISSAL FROM THE PROGRAM

Grounds for dismissal from the BLET program include the following:

1. Violation of BLET program policy or regulations

2. Conviction of any crime, driving while impaired or under the influence (DWI or DUI), major motor vehicle law infractions.

3. Posing a serious threat to the teaching/learning process or to the well-being and safety of students, college personnel, and/or property.

4. Providing false or inaccurate information to college officials at any time.

5. Withdrawal of sponsorship or termination of employment by a public law enforcement agency.

ResourcesBldg. #9 (Student Services)

a. Reading Test AdministeredContact: Kimberly J ackson - 940-6252Shelby Phillips - 940-6443

b. Admissions/Registra r's Office Complete a BCCC ApplicationEnroll as student only.

c. Financial Aid Services. You do not register for BLET

Registration takes place on the first day of the Ac ademy.

Bldg. #1a. Business Office Upstairs.b. Scholarship Foundation.c. Campus Police Office.

Bldg. #5a. Bookstore

Bldg. #10a. Director ( BLET) Larry Barnes - 940-6228b. QA (BLET) Todd Alligood - 940-6499

Bldg. #3a. BLET Assistant Jo Linda Cooper - 940-6208

Beaufort County Community College

Basic Law Enforcement Training Application

5337 Highway 264 EastWashington, North Carolina 27889

Instructions:

Please print this information legibly in ink. If you need additional space, please add pages and identify them by the question number.

NAME ___________________________________________________

READING SCORE ______________

This form is to be turned in to the BLET School Director

THIS IS NOT AN APPLICATION FOR EMPLOYMENT

02/14 rev

PERSONAL

1. Name _________________________________________________________________First Middle Last

2. Social Security Number ______/_____/______

3. Present Mailing Address ___________________________________________________Street and Number

______________________________________________City State Zip Code

4. Permanent Mailing Address ________________________________________________Street and Number

____________________________________________City State Zip Code

5. Telephone Number: Home _____________________ Work _______________________

6. Date of Birth _________________ Place of Birth _____________________ City/State

7. Citizenship1 _____ U. S. Citizen _______Other

EDUCA TION

8. If you did not graduate from high school, have you passed the General Educational Development Test (GED) or the High School Equivalency Program?2 ___ yes ___ no

If yes, when and where? ___________________________________________________

FAMILY

9. Person to notify in case of an emergency:

______________________________________________________________________First Last Relationship Phone

1 This is required by NCAC 12 NCAC 09B .0203(a) “ADMISSION OF TRAINEES”2 This is required by NCAC 12 NCAC 09B .0203(g) “ADMISSION OF TRAINEES”

CRIMINAL OFFENSE RECORDS3

Note: Include all offenses other than minor traffic offenses. The following are not minor traffic offenses: DWI, DUI, failure to stop in the event of an accident, driving while license is revoked, and driving while license is permanently suspended. Answer all of the following questions completely and accurately. Any falsifications or omissions will disqualify you from participation. If you are in doubt about a charge, answer, "Yes". Answer, "No" only if you are sure that you have not been charged or that your record has been expunged by a judge's Court order.

10. Have you ever been arrested by a law enforcement officer or otherwise charged with a criminal offense? ___ yes ___ noIf yes, give details: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

11. Have you ever been charged or convicted with a felony? ___ yes ___ noIf yes, give details:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

12. Have you ever been placed on probation? ___ yes ___ no If yes, give details_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

13. Can you operate a motor vehicle? ___ yes ___ no If no, give details:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

14. Do you possess a driver's license from the State of North Carolina? ___ yes ___ no

If yes, give____________________________________________________________Driver's License Number Date Issued

3 This is required by NCAC 12 NCAC 09B .0203(i) “ADMISSION OF TRAINEES”

15. Do you possess a driver's license issued by any state other than North Carolina?

___ yes ___ no

If yes, give __________________________________________________________State, license number date issued

16. Has your license ever been suspended or revoked? ___ yes ___ no If, yes, give reasons:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

17. Was your license restored? ___ yes ___ no

18. Have your driving privileges been restricted? ___ yes ___ noIf yes, give restrictions.____________________________________________________________________

CAREER PLANS

19. Briefly tell why you want to apply for this course.______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

20. List special skills, training, special licenses, certifications, interests, or hobbies, which may be useful in Basic Law Enforcement Training._________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

RESIDENCES SINCE ADULTHOOD

21. List all permanent or temporary (3-6 months) places of residence since reaching adulthood.

Address City County State Country

I hereby certify that each and every statement on this form is true and complete and understand that any misstatement or omission may disqualify me from Basic Law Enforcement Training

_____________________________________________________________________________________Applicant’s Signature Date

SPONSORSHIP

You should be sponsored by a law enforcement agency within North Carolina. To gain sponsorship follow this procedure. Sponsorship does not mean the agency will pay for your books or tuition. It does not mean they will hire you when you finish. It just means they have checked your criminal record and have found not anything on you.

1. Contact your local police department or sheriff s office and ask them to sponsor you.

2. If they do not agree, contact me immediately by email or by phone. Be prepared to tell me what department you called, who you talked with, their telephone number, and what reason they gave you for not sponsoring you. I will let you know how to proceed after that.

3. If they agree to sponsor you, make an appointment to receive the sponsorship.

4. When you go the appointment, dress professionally. I suggest a suit or coat and tie for males and a jacket, dress blouse and dress pants or skirt for females, As a minimum, you should be well dressed and not wear jeans or shorts.

5. Use the form in this packet to request sponsorship. If an agency head wishes to use his or her own letter or sponsorship form, that is okay.

SPONSORSHIP FORM

BEAUFORT COUNTYCOMMUNITY COLLEGE

BASIC LAW ENFORCEMENT TRAINING

FROM: ___________________________________________________________________

AGENCY NAME: __________________________________________________________

I, __________________________________, have conducted a background investigation on(print name) .

(Sponsorship applicant) Signature of Investigator

The applicant has no record, received by this agency, that would bar them from admission as a trainee under the North Carolina Administrative Code ( 12 NCAC 09B .0203 ADMISSION OF TRAINEES) of the North Carolina Criminal Justice Standards Commission and/ or the North Carolina Sheriffs' Education and Training Standards Commission (Copy of relevant Code section attached).

Our department will sponsor this individual in name only. We will not be responsible for costs, conduct, or any other action that could result in liability for our department. This sponsorship should be used to secure this individual a position in the next offering of the Basic Law Enforcement Training program at Beaufort County Community College and also grant them a tuition waiver. I understand that I am only responsible for an accurate background/record check of this individual and can require the individual to access their records through their county courthouse prior to our recommendation for sponsorship.

_____ Fall/ Spring BLET Academy

Start Date ______________

End Date _______________

Sincerely,

Agency Head

Date

High school diploma or copy of GED certificateProvide a copy of your high school diploma or copy of certificate or a two-year or four-year degree of any college you have attended. Official transcripts are necessary for the Admissions Office only, not for BLET packet.

Proof of citizenship: Provide copy of birth certificate.

Proof of driver's license: Provide copy of current, valid driver's license.

Medical forms:

1. Read all of the medical/physical forms carefully.

2. Call your family doctor for an appointment. If you don't have a family doctor, any doctor, physician’s assistant, or nurse practitioner will do. The local county health department may have a doctor for physicals.

3. Fill out the Medical History Statement (Form F-1) before seeing a physician. This form must be answered completely and honestly. Failure to answer all questions may lead to revocation of certification or dismissal from the BLET program.

4. Give the Medical History Statement and the Medical Examination Report (Form F-2), and OC Pepper and Tear Gas release form to a physician, physician's assistant, or nurse practitioner. Have your medical representative sign and stamp the OC Pepper and Tear Gas form saying that it is safe for you to be exposed to OC Pepper and Tear Gas.

5. By Federal Law, I must have your permission to keep any medical records or to release medical records to the Training and Standards Commission. This permission is given by your signature on the medical records.

CRIMINAL JUSTICE EDUCATION AND TRAINING STANDARDS COMMISSION

CRIMINAL JUSTICE STANDARDS DIVISIONPost Office Drawer 149, Raleigh, NC

27602 Telephone: (919) 661-5980Fax (919) 779-8210

MEDICAL EXAMINATION REPORT Form F-2(LE) (Rev. 3/16)

Instructions:To be completed by a qualified medical professional (Physician, Physician’s Assistant, or Nurse Practitioner licensed to practice medicine in North Carolina, or Physician and/or Surgeon authorized to practice medicine in accordance with the rules and regulations of the U.S. Armed Forces, [12 NCAC 9B .0104(a)], following an actual physical examination. The original or a copy of this report must be retained in personnel files by the appointing agency.

Date: Last 4 Digits SSN:

Name:

Last First Middle

Date of Birth:

Employing Agency:

Height:

Weight:

Vision

Visual Acuity: If applicant wears glasses or contacts, test and record acuity with and without glasses

Without glasses: R - 20 /

L- 20 / Both - 20 /

With glasses: R - 20 /

L- 20 / Both - 20 /

With contacts: R - 20 / How long have contacts been worn?

L- 20 / Both - 20 /

Color Perception: Normal Abnormal:

Peripheral Vision: Normal Abnormal:

This information is for official use only and will not be released to unauthorized persons. Payment for services rendered is the responsibility of the hiring agency

or the individual.The Criminal Justice Standards Division is NOT responsible for payment.

Mail form to hiring agency or individualDO NOT mail form to Criminal Justice Standard Division

Hearing

Hearing Acuity: Audiogram or 15' whispered conversation (check one)

Right ear: Normal Abnormal:

Left Ear: Normal Abnormal:

Page 1 Form F-2(LE) rev.3/1

Cardiovascular

Blood Pressure:

Resting Pulse:

Cardiac Examination: Normal Abnormal:

Peripheral Circulation: Normal Abnormal:

ECG: Indicated by hx or exam: Abnormal Findings

(If resting pulse is less than 50 or greater than 100)

HEENT: Normal Abnormal

Lungs: Normal Abnormal

Abdomen: Normal Abnormal

Musculoskeletal: Normal Abnormal

Genitourinary: Normal Abnormal

Neurological: Normal Abnormal

Skin: Normal Abnormal

Urinalysis Normal Abnormal TB Risk Questionnaires Administered: Yes No Additional Screening Required: Yes No

Specify Additional Screening:

Are there any conditions, physical, emotional or mental, which, in your opinion, suggest further examination?No Yes:

Do you have any reservations about this candidate’s ability to physically perform required duties?No Yes:

I have read and fully understand the Medical Screening Guidelines Implementation Manual for the certification of Criminal Justice Officers in the State of North Carolina.

Signature of Qualified Medical Professional Medical License # Date

Name and Address of Qualified Medical Professional (Please Type)

Page 2 Form F-2(LE) rev.3/16

Tuberculosis Risk Questionnaire

1) Were you born outside the USA in one of the following parts of the world: Africa, Asia, Central America, South America or Eastern Europe?

Yes No

2) Have you traveled outside the USA and lived for more than one month in one of the following parts of the world: Africa, Asia Central America, South America or Eastern Europe?

Yes No

3) Do you have a compromised immune system such as from any of the following conditions: HIV/AIDS, organ or bone marrow transplantation, diabetes, immunosuppressive medicines (e.g. prednisone, Remicade), leukemia, lymphoma, cancer of the head or neck, gastrectomy or jejeunal bypass, end-stage renal disease (on dialysis), or silicosis?

Yes No

4) Have you ever done one of the following: used crack cocaine, injected illegal drugs, worked or resided in jail or prison, worked or resided at a homeless shelter, or worked as a healthcare worker in direct contact with patients?

Yes No

5) Have you ever been exposed to anyone with infectious tuberculosis? Yes No

Tuberculosis Symptom Questionnaire

Do you currently have any of the following symptoms?

1) Unexplained cough lasting more than 3 weeks Yes No

2) Unexplained fever lasting more than 3 weeks Yes No

3) Night sweats (sweating that leaves bedclothes and sheets wet) Yes No

4) Shortness of breath Yes No

5) Chest Pain Yes No

6) Unintentional weight loss Yes No

7) Unexplained fatigue (very tired for no reason) Yes No

Page 3 Form F-2(LE) rev.3/1

CRIMINAL JUSTICE EDUCATION AND TRAINING STANDARDS COMMISSION

MEDICAL HISTORY STATEMENT Form F-1(LE) (Rev. 6/11)

Instructions:To be completed by applicant for a certifiable position prior to the physical examination and presented to the examining qualified medical professional (Physician, Physician’s Assistant, or Nurse Practitioner licensed to practice medicine in North Carolina), or Physician and/or Surgeon authorized to practice medicine in accordance with the rules and regulations of the U.S. Armed Forces, at the time of examination [12 NCAC 9B .0104(a)]. All questions must be answered completely and accurately. The original or a copy must be retained in personnel files by the appointing agency.

Date: _____________________

Name: _______________________________________________ Date of Birth: ____________________Last First Middle

Address: _____________________________________________________________________________

City: ____________________________________ State: ___________________ Zip Code: __________

Telephone: ___________________________________ Last 4 Digits of SSN: ______________________

Current MedicationsPrescription Medications: (Include pain relievers, birth control pills, etc.)_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Over the Counter Medications: (Include all cold allergy, headache, vitamins, supplements, herbal remedies, etc.)_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

AllergiesDrug Allergies: (Include your reaction to the mediation)_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

All Other Allergies: food, insects, seasons, animals, materials, etc. (Include reaction)_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

This information is for official use only and will not be released to unauthorized persons.Payment for services rendered is the responsibility of the hiring agency or the individual.

The Criminal Justice Standards Division is NOT responsible for payment.Mail form to hiring agency or individual

DO NOT mail form to Criminal Justice Standard Division

CRIMINAL JUSTICE STANDARDS DIVISIONPost Office Drawer 149, Raleigh, NC 27602

Telephone: (919) 661-5980Fax (919) 779-8210

Page 1 F-1(LE) Rev. 6/11PAST MEDICAL HISTORYList ALL hospitalizations and operations since childhood: (Include type of surgery, date of surgery, any complications or other significant information)

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Have you EVER , in your life, had any of the following types of medical problems? [Check all that apply to you.]

1. CANCER: any type of cancer including skin cancer, breast cancer, and leukemia? 2. MAJOR INFECTIOUS DISEASE: such as tuberculosis, hepatitis, HIV/AIDS, rheumatic fever

and others? 3. NEUROLOGICAL PROBLEMS: such as seizure disorder, stroke, concussion, severe

headache, skull fracture, recurrent vertigo, balance problems, encephalitis, meningitis, tremors, multiple sclerosis, Huntington’s chorea, peripheral neuropathy and others?

4. PSYCHOLOGICAL PROBLEMS: such as depression, manic episodes, psychotic episodes, post-traumatic stress disorder and others?

5. EYE PROBLEMS: such as eye injury, color blindness, poor night vision (night blindness), glaucoma, blindness in one or both eyes, very poor vision when not corrected and others?

6. EAR PROBLEMS: such as ear injury, chronic ringing (tinnitus), chronic or long lasting ear infection, Meniere’s disease, moderate to severe hearing loss in one or both ears and others?

7. NOSE PROBLEMS: such as nose injury, allergies, nasal bleeding, loss of sense of smell, chronic or long lasting infections and others?

8. MOUTH OR THROAT PROBLEMS: such as injury, major dental work, any kind of speech defect, chronic or long lasting infections, abnormality of nose, mouth or throat that would interfere with wearing a respirator and others?

9. LUNG PROBLEMS: such as asthma, emphysema, chronic or recurrent bronchitis, pneumonia, tuberculosis or lung abscess and others?

10. HEART AND CIRCULATION PROBLEMS: such as heart murmur, heart disease, heart attack, irregular rhythm, valve abnormalities, varicose veins, phlebitis, peripheral vascular disease, Raynaud’s disease and others?

11. DIGESTIVE SYSTEM PROBLEMS: such as any kind of ulcer disease, hepatitis or liver disorder, any kind of colitis, Crohn’s disease, ulcerative colitis, irritable bowel syndrome, esophageal disorders, pancreatitis, gall stones, stomach or intestinal bleeding and others?

12. HORMONE OR ENDOCRINE PROBLEMS: such as diabetes, thyroid disease, parathyroid or adrenal problems and others?

13. URINARY TRACT PROBLEMS: such as kidney stones, pyelonephritis (kidney infection), nephrosis, single functioning kidney, polycystic kidney disease, repeated bladder infections and others?

14. HERNIA: such as inguinal, umbilical, ventral, femoral, hiatal or incisional hernias? 15. MUSCLE, BONE AND JOINT PROBLEMS: such as chronic back or neck pain,

fibromyalgia, back or neck disk disease, osteomyelitis (bone infection), muscular dystrophy, arthritis, spinal curvature, loss of a finger or toe, and others?

16. BLOOD SYSTEM PROBLEMS: such as anemia, hemophilia or bleeding disorder, white blood cell abnormality and others?

(Continued on next page)

Page 2 F-1(LE) Rev. 6/11

MALES ONLY:

17. Prostate problems such as enlargement or prostatitis? 18. Genital problems such as epididymitis or testicular injury?

FEMALES ONLY:

19. Currently pregnant? 20. History of endometriosis, pelvic inflammatory disease, abnormal Pap smear, PMS or other problem

with your menstrual cycle?

IMMUNIZATIONS

21. Have you ever had a positive TB test? 22. Have you received Hepatitis B vaccinations? 23. When did you receive your last tetanus (lockjaw) immunization?_______________________

OCCUPATIONAL HISTORY

Have you ever been exposed to any of the following, whether at home, work, military or any other setting? [Check all that apply.]

24. Repetitive Loud Noises (Including guns, jet engines, loud machinery)? 25. Chemical exposure to skin or lungs? 26. Dusty conditions (sandblasting, grinding, mining or drilling of rock, coal, silica, asbestos)?

Check all YES answers:

27. Have you ever sustained an injury while at work that needed extended care by a health care provider? 28. Have you ever had a motor vehicle accident causing back or neck pain? 29. Are you limited or unable to perform any physical activity because of muscle or joint discomfort? 30. Do you have any missing limbs or non-functional joints? 31. Do you have numbness, weakness, or pain in your upper extremities (including your hands)? 32. Have you ever been advised by a physician to avoid sitting or standing over a certain time? 33. Have you ever worked in law enforcement? 33a. If yes, have you ever missed more than three consecutive days of work for any medical or

psychological problem? 34. Have you ever served in any of the armed forces? 34a. If yes, have you ever missed more than three consecutive days or service for any medical or

psychological problem? 35. Do you have any medical condition that would prevent you from working extended shift periods,

rotating shifts, or night shifts? 36. Do you have any difficulty sitting for any extended period of time? 37. Have you ever been advised by a physician to avoid lifting above a certain weight limit? 38. Do you have any difficulty in properly holding, aiming or firing a handgun, rifle or shotgun? 39. Do you have any difficulty driving at high speeds in a motorized vehicle? 40. Have you ever had an automobile accident while driving over sixty (60) miles per hour? 41. Have you ever had any automobile accidents as a result of losing control of your vehicle? 42. Do you have any difficulty driving for three (3) consecutive hours without stopping? 43. Do you have any difficulty running for five (5) consecutive minutes without stopping? 41. Have you ever passed out, temporarily lost control of any part of your body, or had blackout spells

(episodes you do not remember)?

(Continued on reverse side)

Page 3 F-1 (LE) Rev. 6/11

EXPLANATION OF ANY YES ANSWERS: (Identify by number)Additional pages may be attached and must include your name, the last four digits of your social security number, and must be signed and dated.

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

PENALTY:Any falsification, withholding or failure to answer all questions completely and accurately may disqualify you from receiving or retaining employment or certification as a criminal justice officer. Falsification regarding pre-existing conditions may disqualify you from receiving benefits from your employer.

CERTIFICATION:I hereby certify that there are no willful misrepresentations, omissions or falsifications in the foregoing statements and answers to questions, and that all statements and answers are true and correct to the best of my knowledge and belief.

_____________________________________________ ___________________Signature of Applicant (Use Ink) Date Signed

Qualified Medical Professional Review:

___________________Signature of Qualified Medical Professional (Use Ink) Date Reviewed

________________________________________________________________________________Name and Address of qualified medical professional completing review- Please Type or Print

Page 4 F-1(LE) Rev.6/11

Beaufort County Community CollegeBasic Law Enforcement Training

5337 Hwy 264 EastWashington, NC 27889

(252) 940-6228

RELEASE FORMEXPOSURE TO TEAR GAS, MACE, AND OLEORESIN CAPSICUM (OC PEPPER SPRAY)

Student: ______________________________________(Full Name)

TO THE EXAMINING PHYSICIAN:During Basic Law Enforcement Training, this individual will be exposed to tear gas and oleoresin capsicum (OC Pepper Spray). Individuals with respiratory difficulties including asthma are not suitable candidates for this training and/or employment. Please certify that this individual is physically able to engage in training exercises using tear gas, mace, and pepper mace.

ACCEPTABLE TO PARTICIPATE IN ABOVE ACTIVITIES INCLUDING EXPOSURE TO TEAR GAS, MACE, AND PEPPER MACE:

_______________________________Physician's Signature

Physician’s Stamp or printed name

Beaufort County Community College5337 Hwy. 264 East

Washington, NC 27889(252) 946-6194

Basic Law Enforcement Training

To the Clerk of Court:

This individual is in the process of applying for admission to the Basic Law Enforcement Training Academy at Beaufort County Community College. We need a criminal history from every county that the student candidate has lived in since the age of 18. For the state of North Carolina, that age would be age 16. If possible, please run a statewide check on this student candidate to include traffic offenses.

The student candidate is responsible for payment of any fees.

Thank you for your assistance.

Larry BarnesLarry Barnes, School DirectorBasic Law Enforcement Training(252) 940-6228

Many students have expresses an interest in knowing what level of physical fitness they should possess on entering the BLET class.

After talking to the PT instructors, we recommend the student be able to do 2 sets of 20 pushups on the first day of class.

Also, it is recommended the student be able to run or jog a distance of at least one-half mile without stopping.

Part of the final requirements for graduation from the class is the requirement the student correctly completes 2 sets of 20 pushups.

There is no mininum performance level required to enter the BLET program but these are some suggestions that you can work toward between now and the beginning of class.

If you are needing emergency help for some financial aid, you can contact Serena Sullivan at the Beaufort County Community College Foundation located in Bldg. # 1

You can also contact Beaufort County NC Works for assistance if needed.

If you have completed a GED Program and do not have a Certificate, you need to fill out the attached application and send it to the NC Community Colleges for a copy. Once received, return it to the Director of BLET prior to the start of the Academy.

Transcript Request for GED® Test Scores: 1942 - 2001Please read the following information before completing and submitting this request form

Please do not send multiple request forms for the same order. Originating fax machines provide confirmation of a successful transmission. We do not verify receipt of faxes. We provide GED® transcripts and duplicate diplomas from 1942 - 2001 free of charge We do not accept records requests over the phone or Internet We do not provide verifications over the phone or Internet For transcripts, verifications and diplomas from 2002 and later, please go to

http://www.gedtestingservice.com/testers/gedrequest-a-transcript

We are unable to provide transcripts, verifications and diplomas from 2002 and later

Your signature and full Social Security Number are required. Not providing all requested information will delay processing.

NC Adult High School transcripts are obtained from the college where the diploma was awarded; not the HSE Records Office

We do not fax transcripts. Please allow 10-25 business days to process requests.

Student Information

Name Name used during testing (maiden name, etc.)

Current Mailing Address Date of Birth

Current City, State and ZIP Code Where did you test? (NC Community College, correctional facility, etc.)

Full Social Security Number Daytime Contact Telephone Number

What is the approximate year you tested? Student Signature

To obtain a GED® transcript for a credential received in the military prior to September 1974, please contact: DANTES Test Control 1-877-471-9860

Transcript 1: Mail to the address below. Transcript 3: Mail to the address below.

Name Name

Street Address (include Apartment, Lot, Suite or Unit numbers) Street Address (include Apartment, Lot, Suite or Unit numbers)

City, State and ZIP Code City, State and ZIP Code

Transcript 2: Mail to the address below. Duplicate Diploma: Mail to home address

Name Name

Street Address (include Apartment, Lot, Suite or Unit numbers) Street Address (include Apartment, Lot, Suite or Unit numbers)

City, State and ZIP Code City, State and ZIP Code

Please send this form via mail or fax to:NCCCS High School Equivalency (HSE) Records Office: 5016 Mail Service Center, Raleigh, NC 27699-5016FAX: 919-807-7172 or 919-807-7164Jan 2017 http://www.nccommunitycolleges.edu/college-and-career-readiness/high-school-equivalency

Official North Carolina Transcript RequestPlease read the following information before completing and submitting this request form

The GED® Records office receives numerous requests for transcripts each day. In order to serve the public most efficiently, we kindly ask individuals to not send multiple request forms for transcripts and to allow 20-25 business days to pass before inquiring if a request has been processed.

Originating fax machines provide “confirmation of successful transmittal,” which serves as your confirmation that our office received your request. We do not verify receipt of transcript or verification requests.

We provide North Carolina GED® transcripts free of charge. Duplicate diplomas are not available. Your signature and social security number is required. Not providing ALL requested information will delay the processing of

your request. North Carolina Adult High School transcripts can be obtained from the college where the diploma was issued; not from the

GED® Records Office. We do not fax transcripts. A transcript must contain our raised state seal and be delivered in an unopened envelope to be

considered official.

Student Information

Your Name Your Name used during testing (maiden name, etc.)

Your Street Address Your Date of Birth

Your City, State and ZIP Code Where did you test? (NC Community College, etc.)

Your Social Security Number Your Daytime Contact Telephone Number

What is the approximate year you tested? Student Signature

To obtain a transcript for a GED® received in the military prior to September 1974, please contact:DANTES Test Control 1.877. 471.9860

Transcript 1: Please mail to the address below. Transcript 2: Please mail to the address below.

Name Name

Street Address (include Apartment, Lot, Suite or Unit numbers) Street Address (include Apartment, Lot, Suite or Unit numbers)

City, State and ZIP Code City, State and ZIP Code

Transcript 3: Please mail to the address below. Transcript 4: Please mail to the address below

Name Name

Street Address (include Apartment, Lot, Suite or Unit numbers) Street Address (include Apartment, Lot, Suite or Unit numbers)

City, State and ZIP Code City, State and ZIP Code

Please send this form via mail or fax to:

NC GED® Records Office5016 Mail Service CenterRaleigh, NC 27699-5016

Fax: 919.807.7172 or 919.807.7164

September 2012

http://www.nccommunitycolleges.edu/college-and-career-readiness/high-school-equivalency/high-school-equivalency-records